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June 28, 2011

Will Individualized Medicine Increase Health Inequality?

by Brad Warbiany

Ezra Klein has a rather thought-provoking post today about human genome sequencing and its ability to allow doctors to better-tailor treatment to the specific needs of an individual patient. It presents a phenomenal opportunity to both make medicine more effective, and IMHO to make it cheaper by spending less time and energy on substandard treatments. Ezra raised a different point, though, and I think makes a logical error that warrants further discussion:

If that’s the path that medical advances ultimately take, one byproduct will be an immense explosion in health inequality. Right now, health inequality, though significant, is moderated by the fact that the marginal treatments that someone with unlimited resources can access simply don’t work that much better than the treatments someone with more modest means can access. In some cases, they’re significantly worse. In most cases, they’re pretty similar, and often literally the same.

But as those treatments begin to work better, and as we develop the ability to tailor treatments to individuals, we should expect that someone who can pay for the best treatments for their particular DNA sequences to achieve far better health-care outcomes than someone who can’t afford the best treatments and has to settle for general therapies rather than individualized medicine.

I believe Ezra makes assumes the premise that the “best” treatments are also the most expensive treatments. I believe this to be unsupported by evidence.

Suppose 10 different people all happen to have the same malady. To use a common one, let’s say that the malady is hypertension. Multiple drugs today exist for the treatment of hypertension. Some of them may be specific variants (branded or generic) of medications all within a specific class, but often multiple classes of drugs may be used to treat hypertension. Those multiple classes will affect different people in different ways, but my guess is that a typical doctor will offer a “standard” treatment regimen for hypertension and only deviate from that standard if something doesn’t appear to be effective. What’s further important to note is that different doctors may have different “standard” regimen, based on their own experience rather than exact current medical literature.

What the idea of genome sequencing may bring to the table is that medical research can form stronger predictions of a particular person’s response to certain medicines based upon their specific genes, and it is easier to tailor the treatment to the patient. This doesn’t mean that the rich person’s treatment will be more expensive than a poor person’s, but it does mean that someone who has genome sequencing will likely have more effective treatment than someone who does not. What it also means is that someone who has genome sequencing may actually have less expensive medical treatment than someone without, as less effort and dollars can be used adding treatments that are statistically likely to be ineffective.

And herein lies the rub. Will a rich person have better access to genome sequencing than a poor person? Not if we have Ezra’s wet dream: government socialized health care. Once effectiveness at reducing costs is shown, government in its awesome authoritarian-ness will undoubtedly use the desire for cost-cutting in medical treatment to demand genome sequencing of anyone participating in Obamacare. Sure, we civil libertarians will soundly object to government getting access to everyone’s DNA, but I’m sure they’ll tell us, much like they do with the TSA pornoscanners and told us with our social security numbers, that there’s NO CHANCE the genome information will ever be used for anything other than our medical care, and will be completely confidential. And since nobody listens to us civil libertarians today, they’ll get it done.

If Ezra looks at the potential from this angle, I think he’d change his tune. If he sees genome sequencing as a potential cost-cutting measure, rather than an inequality-increasing measure, I’m sure he’d actually push for wider adoption of it. And like any government authoritarian impulse, if something is good [and if we're paying for it with tax dollars], we might as well make it mandatory, right?

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3 Comments

  1. In your example of hypertension, the best care (without regards to cost) would be a rapid panel of gene tests that would identify factor contributing to hypertension and indicate the best drug and its most optimal dosage. This technology doesn’t exist and would be costly if it did.

    The best care available today also happens to be almost the least expensive. It’s known as a trial of therapy. The physician evaluates the patient and prescribes the lowest cost anti-hypertensive drug that’s likely to work. Blood pressure is monitored frequently, and the patient records side-effects. Dosage is adjusted based on those outcomes. If the drug is ineffective or has too many side-effects, a different drug is chosen, and the process is repeated.

    By my estimate, properly applying this type of process could improve the quality of care substantially while reducing costs of care by at least one-third. Achieving this requires better-trained clinicians, not massive government intervention.

    Comment by Dr. T — June 28, 2011 @ 2:36 pm
  2. Dr. T,

    This technology doesn’t exist and would be costly if it did.

    I think it may not exist today, and is likely would be much more costly today if it did that it might be a decade down the road.

    I suspect that at some point in the future it might be feasible and cost-effective to have this sort of testing available. I’m sure today it’s significantly more detailed than the current commercially-available genomic testing, but we’re talking about a technology in its absolute infancy. Costs will come down and availability will increase.

    At some point in the past, x-rays didn’t exist, and when they first appeared, I’m sure they were quite pricey. Now, as someone who had a wisdom tooth extracted last Tuesday (and has the bill right in front of me), the entire panoramic xray of my teeth was a $109 fee (total, which was all covered by insurance — i.e. this is not the “discounted” fee). The big-ass flatscreen on the wall that they used to display my panoramic cost more than getting the x-ray taken ;-)

    Comment by Brad Warbiany — June 28, 2011 @ 3:56 pm
  3. Will also be interesting to watch the market effect influence those with outlying genome sequences.

    Excessive focus on the few central sigma of the population will lead to accelerated advancement of the generic and decline of the unique, and any such process that creates such evolutionary weaknesses must be guarded against.

    Worse still would be a focus on the fewer sigma that constitute the upper percentages of wealth ownership. As the wealthy have become the nobility they have begun to exhibit the same traits as historic noble figures. Based on those tendencies witnessed historically, noble genomes created from too narrow a pool create a negative evolutionary effect.

    Comment by Huxwellisbadmkay — July 2, 2011 @ 2:19 pm

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